Abstract

Legislation and practice of involuntary hospital admission vary
substantially among European countries, but differences in outcomes have not
been studied.

Aims

To explore patients’ views following involuntary hospitalisation in
different European countries.

Method

In a prospective study in 11 countries, 2326 consecutive involuntary
patients admitted to psychiatric hospital departments were interviewed within
1 week of admission; 1809 were followed up 1 month and 1613 3 months later.
Patients’ views as to whether the admission was right were the outcome
criterion.

Results

In the different countries, between 39 and 71% felt the admission was right
after 1 month, and between 46 and 86% after 3 months. Females, those living
alone and those with a diagnosis of schizophrenia had more negative views.
Adjusting for confounding factors, differences between countries were
significant.

Conclusions

International differences in legislation and practice may be relevant to
outcomes and inform improvements in policies, particularly in countries with
poorer outcomes.

Throughout the world significant numbers of people are admitted
involuntarily to psychiatric hospital departments. How involuntary hospital
admissions should best be legislated for and regulated is
controversial.1–3
In the UK, the government has proposed two bills for a new mental health act
in England and Wales since 2002. Following the wide resistance of professional
groups, user organisations and parts of the media, both bills were withdrawn
and the government settled for an amendment to the existing 1983
Act.4,5

The debate on the most appropriate regulations and practice for involuntary
hospital admission is guided by little, if any, research. There is no evidence
about whether specific procedures are associated with different
outcomes.6,7
Ethical and practical reasons may prevent experimental designs such as
randomised controlled trials. In their absence, observational comparisons
between sites with different legislation and practice are a viable method to
explore the link between procedures and outcomes.

Countries across Europe share a similar background in terms of societal
systems and history of psychiatry but vary substantially in their legislation
for and practice of involuntary hospital
admission.8,9
Involuntary admission rates vary by a factor of more than
10.1,10
Several studies have analysed the differences in legislation and policies but
there is no evidence yet on whether there also are differences in
outcomes.

Legislation for involuntary admissions is based on the assumption that
individuals cannot recognise the need for hospital care because of the severe
and usually acute symptoms of their illness. This would imply that they should
later (once the acute phase is over) accept that the involuntary admission was
the right intervention at the
time.11
Patients’ retrospective view of the appropriateness of the admission has
been used as an outcome criterion in studies in Australia, Canada, Sweden, the
USA and the
UK.12–18
Between 33 and 81% of involuntary patients found the admission ‘
right’ in retrospect. The rate varied according to the exact
wording of the question and the time since
admission.6

In this study we assessed patients’ views on involuntary hospital
admission after 1 and 3 months at sites in 11 European countries. We explored
whether, and if so, to what extent, patients’ retrospective views on
admission varied between sites in different countries, whether these
differences held true after controlling for differences in patient
characteristics and what baseline patient characteristics were associated with
more or less positive views across countries.

Method

Design and participants

The study was conducted as a multicentre prospective cohort study in 11
European countries: Bulgaria (Sofia), Czech Republic (Prague), Germany
(Dresden), Greece (Thessaloniki), Italy (Naples), Lithuania (Vilnius), Poland
(Wroclaw), Slovakia (Michalovce), Spain (Granada and Malaga), Sweden
(Örebro) and the UK (east London). Between one and five hospitals were
studied in each country. Tel Aviv in Israel was originally included, but
omitted from this analysis because of inadequate study implementation. All
sites had in-patient units with voluntary as well as involuntary patients.
Involuntary admissions were conducted according to national legislation and
routine practice. The rationale and methods of the study, the characteristics
of the participating hospitals and data about other mental health services in
the catchment areas of the hospitals have been described in detail
elsewhere.19 The
inclusion criteria were: all in-patients in general psychiatric departments;
admitted involuntarily; aged between 18 and 65 years; resident in the
catchment area; with sufficient command of the national language; able to give
informed consent. Exclusion criteria were: admission because of intoxication;
primary diagnosis of dementia; transfer from another hospital.

Procedures and measures

Patients were identified by researchers through ongoing contacts with
clinical staff on the wards and the relevant administrators. Clinical staff in
the participating wards introduced eligible patients to a researcher, who
contacted the patient within the first week of admission, provided a full
explanation of the study, and asked for consent. If written informed consent
was obtained, the patient was assessed. This included an assessment of
psychopathological symptoms, which were taken as baseline symptom levels.
Further face-to-face interviews were conducted at follow-up at 1 and 3 months
after admission. Patients were recruited between July 2003 and October
2005.

The primary outcome was the patients’ retrospective view on the
extent to which the admission was right or wrong at 1 and 3 months. Patients
rated their response to the question ‘Today, do you find it right or
wrong that you were admitted to hospital?’ on an 11-point Likert scale
ranging from 0 (entirely wrong) to 10 (entirely right), which has been used in
previous
research.14,15

Baseline sociodemographic and clinical characteristics and the diagnosis of
the patients were obtained from medical records. These included data on age,
gender, living situation (living alone v. living with others),
employment situation (no current employment v. employment), previous
hospitalisations (none v. one or more previous hospitalisations) and
clinical diagnosis according to
ICD–10.20
Diagnoses were collapsed into three groups: schizophrenia or other psychosis
(F20–29), affective disorder (F30–39), and ‘others’.
Researchers assessed baseline symptom levels on the 24-item version of the
Brief Psychiatric Rating Scale
(BPRS)21 which
ranges from 24 to 168, with 168 indicating the maximum symptom severity.
Researchers from all sites had joint training sessions in administering and
rating this instrument and achieved an interrater reliability (intraclass
correlation coefficient) of 0.78. The study was approved by the relevant
national and/or local ethics committees.

Statistical analysis

The outcome variable was the patients’ retrospective view on the
extent to which the admission was right or wrong on an 11-point scale (0,
entirely wrong; 10, entirely right), and was treated as quantitative in the
analysis to fully utilise the variation in patient’s responses and
summarised by mean and standard deviation after examining its distribution. To
present the primary outcome in each country in a clinically more meaningful
manner, we also dichotomised the scale at five (the neutral middle point) and
show the percentage of patients who rated above five indicating that they
viewed their admission as more right than wrong. Descriptive summary
statistics were also used to describe the distributions of the predictors of
the outcome variable.

To account for possible correlations among repeated measurements, a
generalised estimating equation (GEE) model was
employed22 with
patients’ characteristics measured at baseline and time of measurement
as fixed effects and patient as random effect. We performed GEE model analysis
in three steps. First, we performed a univariate GEE model analysis for all
predictors. Predictor variables that were significant at P = 0.05
were subsequently entered in a multivariate GEE model analysis in the second
step. Finally, we checked model assumptions by examining the residual
plots.

The estimated effects of predictors on the primary outcome from the GEE
models are reported together with their 95% confidence intervals. To identify
the between-country differences, we derived a matrix of P-values for
all possible pair-wise between-country comparisons from the estimated
multivariate GEE model.

In England, age, gender, and clinical diagnosis were obtained for all
eligible patients in the study including those who were not interviewed
(approved by the Patient Information Advisory Group; ref: PIAG 2-10(d)/2005).
Interviewed and non-interviewed patients were compared on the assessed
characteristics to estimate a potential selection bias in the recruitment
process.

Results

Sample characteristics

A total of 2326 patients were recruited in all countries and assessed at
baseline. Table 1 shows the
number of eligible patients and the selection process in each country.

Between 31 and 71% of eligible patients were interviewed within the first
week of admission, and of these between 63 and 96% were followed up at 1
month, and between 55 and 93% at 3 months.

The characteristics of the participating patients are summarised in
Table 2. Overall, 72% of
patients were without employment, 66% lived alone, 71% had been hospitalised
before and 62% were diagnosed with schizophrenia.

Baseline characteristics of participating patients at sites in all
countries and hospitalisation status at 1-month and 3-month follow-up

At the English site, baseline data were obtained for 181 out of those 183
patients who were eligible but not interviewed. Their mean age was 36.01 years
(s.d. = 11.41). Of these, 40% were female, 60% diagnosed with schizophrenia,
22% with affective disorders and 18% with ‘other’ diagnoses. The
interviewed and non-interviewed patients were similar on the tested
characteristics listed in Table
2.

The baseline characteristics of patients in the total sample followed up at
1 month (and at 3 months) were: 45.1% (45.5%) female; 73.1% (72.2%)
unemployed; 35.3% (36.0%) living with others; 71.4% (72.3%) with a previous
hospitalisation; 65.7% (64.7%) diagnosed with schizophrenia, 16.7% (17.2%)
with affective disorders and 17.6% (18.1%) with ‘other’ diagnoses.
The mean age of those followed up at 1 month was 38.87 years (s.d. = 11.21),
and of those followed up at 3 months 39.10 years (s.d. = 1.13). The baseline
BPRS mean score of those followed up at 1 month was 54.77 (s.d. = 15.84) and
of those followed up at 3 months 55.08 (s.d. = 15.84). The assessed
characteristics of the originally recruited sample and the samples followed up
at 1 and 3 months were similar.

Patients’ views on whether admission was right

Table 3 shows the percentage
of patients who thought that the admission was right, as well as the means and
standard deviations of their ratings for each country and each follow-up.

Factors associated with patients’ views

The univariate associations of all considered predictor variables including
country of site with the outcome and the findings of the multivariate analysis
are shown in Table 4.
Table 5 shows which differences
between countries were significant in pair-wise post hoc comparisons,
adjusting for the influence of all other significant predictor variables.

Patients’ views on the appropriateness of their involuntary admission
show significant differences between sites in different countries, even when
adjusted for other predictor variables. The post hoc comparisons show
that not all differences between sites in different countries were
statistically significant, but the more substantial ones were, for example,
patients’ views in England are significantly less favourable than those
in Bulgaria, Greece, Spain, the Czech Republic, Italy, Germany and Slovakia,
whereas patients’ views in Slovakia are significantly more positive than
in all sites other than those in the Czech Republic, Italy and Germany.

All predictor variables considered further other than previous
hospitalisation showed significant associations with outcomes in univariate
analyses. In the multivariate analysis however, only gender, living situation
and diagnosis were significantly associated with patients’ views. Male
patients and those living with others tended to find the admission more often
right. Patients with schizophrenia had more negative views than those with
other diagnoses.

Discussion

Main findings

One month after involuntary hospital admission, between 39 and 71% believed
the admission was right. After 3 months, when the acute phase of the mental
illness justifying the involuntary admission should be overcome for most
patients, the rates are higher and range between 46 and 86%. The findings that
a substantial proportion of patients do not agree retrospectively with the
appropriateness of the admission may shed a critical light on the ethical
justification of involuntary hospital admission. At the same time, an average
of 63% found the admission right 3 months later which may be a reassuring
finding for many clinicians, patients and their families. The figures are
consistent with previous studies with smaller samples and usually less
systematic
methods.6,14,23,24
However, what is a totally new finding is the large variation across sites in
different European countries. This variation is not explained by differences
in sociodemographic characteristics, clinical diagnoses or baseline symptom
levels considered in this study. The size of the differences are substantial,
and many of them are statistically significant.

Strengths and limitations

This is the largest prospective study on outcomes of involuntary hospital
admissions ever conducted and the first one to use the same methods across
sites in a number of countries. It included centres in 11 European countries
with different legislation and practice in involuntary admission. All patients
were assessed face to face by trained researchers, and were recruited and
interviewed within the first week of admission, which is challenging given
that many patients had high symptom levels and all of them were in the
hospital on an involuntary basis.

The study has a number of weaknesses: overall, only 50% of the eligible
patients were interviewed, and the rate varied across countries. The rate may
be seen as low in many other fields of health research, but has been described
as good for these types of studies in acute settings with patients who are
difficult to
recruit.6 For
comparison of recruited and non-recruited patients, data were only available
for the English site, although both the followed up and non-followed up
patients were compared at all sites. These comparisons did not suggest a
selection bias on the assessed characteristics, neither for the recruitment of
eligible patients nor for the follow-ups. However, only a few characteristics
were assessed.

We only studied between one to five hospitals in each country and do not
know to what extent the data are representative for the country as a whole. In
England we have data from a linked national study to estimate
this.24 The English
sites in this international study were two hospitals in the London boroughs of
Hackney and Newham. In 20 other hospitals, the same outcome data were assessed
in 371 involuntary patients at 1 month and in 307 patients at 3 months. At 1
month, 45% (n = 166) of patients felt that the admission was right
(mean score 4.81, s.d. = 3.99), and at 3 months 50% (n = 154)
expressed that view (mean score 5.34, s.d. = 3.94). Outcomes at the two
study-site hospitals in east London and the 20 other hospitals in England were
similar, and using the data of those 20 hospitals would not have substantially
changed the findings of the national comparisons. However, there are no
similar data from other countries to check whether the results at the study
sites are representative for or different from the outcomes at other hospitals
in the country.

Possible reasons for the differences

Can the identified differences in patients’ views about involuntary
admission be linked to the characteristics of the given legislation? There is
no straightforward answer. The legislation in all countries is complex and has
many features that are of potential importance. Any interpretation of the
findings from the identified differences with the characteristics of the
national legislation is a post hoc exercise and inevitably
speculative.

One possible criterion to classify the national regulations is the extent
to which they protect the rights and interests of the patients
concerned.8,9
Seven criteria that vary between countries and may be seen as relevant for the
protection of the interests of the patients are shown in the Appendix.
Although the answers to the questions are not always clear cut, we established
the number of criteria for each country. The resulting ranking has
similarities with the order of outcomes in the multivariate analysis of this
study (with the most protective legislation and most positive patient views in
Slovakia and Germany, and the least protective legislation and most negative
views in England), but the criteria still leave many of the differences in
patients’ views unexplained.

A number of other national features might be important. These include the
geographical position and political history (e.g. Western v. Eastern
Europe), the relative expenditure of healthcare funding on mental
healthcare,25 the
overall rates of involuntary
admissions,2 and the
recruitment and follow-up rates in this study. However, none of these was
clearly associated in our study with the differences identified in
patients’ views. There are three other possible factors accounting for
the differences that were not assessed. First, patients at the various sites
may have differed in relevant social or clinical characteristics that were not
captured in the study. Second, national differences in the expectations of
patients and overall rating tendencies may have favoured more or less positive
answers to the outcome question. Finally, clinical practice (the behaviour of
professionals towards involuntary patients and the methods employed to support
and treat them) is likely to vary across Europe and impact on outcomes. Some
aspects of clinical practice may be linked to national cultures and traditions
and difficult to change, but others may reflect training and policies that are
transferable to other countries.

Factors associated with outcomes across countries

Some patient characteristics were associated with views on admission across
countries. Females expressed more negative views, as has been reported for
other patient-reported outcomes in psychiatry, although this is not a
consistent
finding.26,27
Patients living alone more often rated the admission as wrong, which may
reflect their difficulties adjusting to the confined space and the often tense
atmosphere with fellow patients and staff on a ward. It may also be that
patients living with others had often experienced conflicts and tension with
these making the admission a relief and therefore the right decision in
retrospect. During and after hospital treatment they are likely to have had
discussions with their partners about their illness and received support from
them. Both discussions and support may have led to more positive appraisals of
the admission. Patients with schizophrenia had more negative views on
admission, which may be linked to a more frequent lack of insight in these
patients.28 In the
multivariate analysis, the degree of baseline symptoms was not associated with
later views about the admission. Thus, this study provides no evidence for the
assumption that a high level of initial symptoms is associated with more
negative views about admission later.

Implications

The findings suggest that the great differences in the legislation and
practice of involuntary hospital admission and subsequent treatment across
Europe may indeed be associated with substantial differences in
patients’ views. Although the exact causal factors and mechanisms remain
poorly understood, the differences between European countries appear to matter
for outcome.29
Future in-depth studies could identify those factors in legislation and
practice that are specifically relevant to achieving more positive views from
patients.30
Countries with currently less favourable outcomes, such as England, might
consider implementing them, and methods may be developed to strengthen these
factors and improve outcomes across all countries.

Funding

This study was funded by a grant from the European
Commission (Quality of life and Management of
Living Resources Programme, contract number
QLG4-CT-2002-01036).

Appendix

Criteria to distinguish the legislation on involuntary hospital
admission with respect to the protection of the interest of the patients

For each question the first option is seen as more protective of the
interest of the patients.

Legislation criteria

Is involuntary admission possible only when patients pose a risk to
themselves and/or others, or also to avoid a more general threat to the
patients’ health?

Can the admission be initiated only by authorities and medical doctors or
also by other stakeholders?

Does involuntary admission require the decision of a court or not?

Is the period of time for which the hospital can decide to keep patients
involuntarily on the wards without a formal decision for involuntary treatment
shorter or longer than 24 hours?

Is legal support guaranteed or not?

With respect to appeal procedures to independent bodies, are there binding
time periods for a response, and are people and/or institutions other than the
patient authorised to appeal, or not?

Is the decision for involuntary treatment measures separate from the
decision for involuntary admission or not?